Postoperative Rehabilitation Protocol Following Reverse Total Shoulder Arthroplasty (RTSA)

Goals:

• Protect the surgical repair and ensure healing of soft tissues.
• Maintain joint integrity.
• Control pain and inflammation.
• Maintain mobility and function of distal joints (elbow, wrist, hand).
• Begin gentle passive range of motion (PROM) within safe limits.

Precautions:

• Wear an abduction sling for comfort and protection (typically 4-6 weeks); can be discontinued earlier based on surgeon’s advice and patient tolerance. For the first 2-3 weeks post-operatively, the sling is typically worn full-time and removed only for hygiene, gentle exercises, and therapy sessions, in accordance with the surgeon’s recommendations.
• Avoid shoulder extension and IR beyond neutral.
• No active shoulder range of motion (AROM).
• Only light, NWB isometrics of scapular stabilizers and deltoid
• No lifting or weightbearing through the operated arm.
• Avoid combined shoulder internal rotation (IR), adduction, and extension (e.g., no reaching behind back or pushing from a chair) for at least the first 6 weeks.
• Protect the subscapularis repair if present; if repaired via superior approach, delay PROM and deltoid isometrics for 3-4 weeks.

Interventions:

• Cryotherapy for pain and swelling control.
• PROM of shoulder in scapular plane: forward flexion and external rotation gradually increased up to 90° and 20-30° respectively, avoiding abduction initially.
• Active and active-assisted ROM (AAROM) of elbow, wrist, and hand.
• Submaximal, pain-free deltoid and periscapular isometrics starting around day 4-7 (avoiding shoulder extension during posterior deltoid activation).
• Pendulum exercises.
• Patient and caregiver education on joint protection and safe movement.

List of Exercises:

• Pendulum exercises.
• Passive forward flexion and external rotation in scapular plane (in supine).
• Active elbow/wrist/hand movements.
• Submaximal deltoid isometrics (without shoulder extension).
• Scapular isometrics.

Criteria to Progress to Phase II:

• Patient tolerates PROM and AROM program for elbow, wrist, and hand.
• Ability to isometrically activate all deltoid components and periscapular muscles without pain.
• No signs of instability or complications.

Goals:

• Gradually restore active shoulder ROM.
• Re-establish dynamic shoulder stability.
• Begin gentle strengthening exercises.
• Submaximal isometric exercises (NWB only)
• Continue pain and inflammation control.
• Maintain joint protection.

Precautions:

• Continue avoiding shoulder hyperextension.
• Restrict lifting heavier than a coffee cup.
• Avoid weightbearing with the operative arm.
• If subscapularis repair was done, limit ER and IR as per surgeon’s instructions.
• Avoid sudden or jerky movements to minimize risk of dislocation

Interventions:

• Progress PROM to AAROM and then AROM in scapular plane (supine progressing to sitting/standing).
• Initiate gentle submaximal isometric external and internal rotation.
• Begin gentle isotonic strengthening of deltoid and periscapular muscles with low load, high repetition.
• Gentle scapulothoracic rhythmic stabilization and alternating isometric exercises.
• Continue cryotherapy as needed.
• Functional activities such as feeding and light ADLs encouraged.
• Restricted lifting with operated arm for 12-16 weeks (no more than a cup of coffee or glass of water)
• Delay resisted rotation to protect subscapularis and teres minor

List of Exercises:

• Pulley-assisted forward flexion.
• Assisted wall slides.
• Active forward flexion (gravity minimized progressing to upright).
• Submaximal ER strengthening in 45° to 90° abduction.
• Isometric deltoid and scapular stabilizer contractions.
• Gentle scapular retractions and protractions.
• Elbow, wrist, and hand strengthening.

Criteria to Progress to Phase III:

• Demonstrated improved shoulder function.
• Ability to isotonically activate all deltoid and periscapular muscles.
• Pain-free AROM with acceptable mechanics.

Goals:

• Enhance functional use of the shoulder.
• Increase muscular strength, endurance, and power.
• Normalize shoulder mechanics.
• Prepare for return to higher-level activities.

Precautions:

• Avoid lifting objects heavier than 2.7 kg (6 lbs).
• No sudden lifting, pushing, or jerking motions.
• Continue joint protection strategies as needed.

Interventions:

• Progressive resisted strengthening of deltoid, rotator cuff, and scapular stabilizers using weights and resistance bands.
• Initiate eccentric and plyometric exercises around 12 weeks.
• Closed chain exercises for proprioception.
• Functional activity simulation and task-oriented exercises.

List of Exercises:

• Supine to standing active forward flexion with light weights.
• Resisted external and internal rotation exercises with therabands or dumbbells.
• Scapular setting exercises progressing to rows and scapular stabilization drills.
• Eccentric strengthening exercises.
• Closed chain proprioceptive exercises.

Criteria to Progress to Phase IV:

• Independent with home exercise program.
• Demonstrates functional pain-free AROM (80°-120° elevation, ~30° ER).
• Sufficient strength and control to perform ADLs safely.

Goals:

• Maintain strength, endurance, and ROM.
• Return to functional and recreational activities within surgeon’s guidelines.
• Prevent complications and overuse injuries.

Precautions:

• Continue lifting restrictions as advised.
• Avoid high-risk activities unless cleared by surgeon/therapist.

Interventions:

• Patient-directed home exercise focusing on continued strengthening and ROM.
• Gradual return to work, sports, and leisure activities.
• Periodic follow-up monitoring.

List of Exercises:

• Continued resistance exercises for deltoid and scapular muscles.
• Stretching and mobility exercises as needed.
• Functional task practice.

• Sling Position Matters: Neutral rotation sling position has been shown to reduce night pain and improve range of motion compared to internal rotation slings, especially in anatomic TSA patients.
• Early Mobilization is Safe: Multiple studies demonstrate that early initiation of passive and active exercises does not increase complication rates, and can improve early function.
• Subscapularis Repair Considerations: When subscapularis is repaired, delayed initiation of ER and IR ROM and strengthening is recommended to protect repair; however, many modern RTSA procedures do not repair subscapularis and allow earlier mobilization.
• Home-based vs. Supervised Therapy: Home exercise programs can be as effective as formal supervised therapy in most patients, reducing costs and patient burden.
• Return to Sport and Activities: Most elderly patients can safely return to low- and moderate-impact sports post-RTSA; however, higher demand activities should be individualized and cautiously approached.
• Deltoid Muscle Focus: Given the altered biomechanics after RTSA, deltoid muscle strengthening is critical for functional recovery. Use biofeedback and progressive loading to optimize deltoid recruitment.

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